Transition Planning and Transition Plans for People in Facilities Sample Clauses

Transition Planning and Transition Plans for People in Facilities. 1. The State, through its community mental health providers and/or other relevant community providers, will provide each individual in NHH and Glencliff with effective transition planning and a written transition plan as set forth below. The written transition plan may be incorporated into the individual’s discharge summary and paperwork from NHH or Glencliff. 2. Transition planning will: (a) begin with the presumption that with sufficient services and supports, individuals can live in an integrated community setting; (b) be developed and implemented through a person-centered planning process in which the individual has a primary role and is based on the principle of self-determination; (c) include persons who have the linguistic and cultural competence to serve the individuals; (d) be based on each individual’s needs and not on the availability, perceived or actual, of current community resources and capacity; and (e) not exclude any individual from consideration for community living based solely on his or her level of disability. 3. The transition planning process will result in an effective written transition plan that: (a) sets forth in reasonable detail the particular services and supports, including their scope, frequency, and duration, that each individual needs in order to successfully transition to and live in an integrated community setting, whether or not a suitable community setting is currently available; such services and supports may include housing, transportation, staffing, mental health care, health care, and other professional services; (b) sets forth which persons and/or organizations have responsibility for delivering needed services and supports before, during, and after the transition; (c) sets forth the date the transition should occur, as well as the timeframes for completion of needed steps to effect the transition; (d) sets forth any barriers to transition to an integrated community setting and how to overcome them, if possible; and (e) sets forth a post-transition schedule of monitoring visits by community mental health providers to the new community setting to assess whether the needs of the individual are being met. 4. In developing the transition plans, the State will make all reasonable efforts to avoid placing individuals into nursing homes or other institutional settings. Before adopting a transition plan that places an individual in a nursing home or other institutional setting, the State must consider all possible altern...